Pediatric Rhinosinusitis - University of Texas Medical Branch · sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 days Severe Acute Sinusitis: purulent

Pediatric Rhinosinusitis

Sarah Rodriguez MD

Faculty Advisor Matthew Ryan MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

May 2004

Anatomy

Maxillary Sinus first to develop at day 65 of gestation seen on plain films at 4-5 months slow expansion until 18 years

Ethmoid Sinus develop in third month of gestation ethmoids seen on radiographs at one year enlarges to reach adult size at age 12

Sphenoid Sinus originates in fourth gestational month from posterior part of nasal cavity pneumatization begins at age 3 rapid growth to reach sella by age 7 and adult size at age 18

Frontal Sinus begins in fourth month of gestation from superior ethmoid cells seen on radiographs at age 5-6 grows slowly to adult size by adolescence

Definitions

Acute symptoms often inseparable from URI and include rhinorrhea daytime cough nasal congestion infrequent low-grade fever otitis media irritability and headache Key in diagnosis of sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 days Severe Acute Sinusitis purulent rhinorrhea high fever periorbital

edema

Recurrent complete resolution between episodes and 3 or more episodes in six months or more than 4 episodes in one year

Subacute signs and symptoms lasting three weeks to three months Chronic signs and symptoms lasting longer than three months

Pathogenesis

Ostia obstruction creates increasingly hypoxic environment within sinus

Retention of secretion results in inflammation and bacterial infection

Secretion stagnate obstruction increases cilia and epithelial damage become more pronounced

Most common inciting event is viral URI

Diagnosis

Physical Examination

Anterior rhinoscopy with otoscope in younger children

Tenderness over sinuses

Periorbital edema and discoloration

Flexible and rigid endoscopy in older child

Most specific-- mucopurulence periorbital swelling facial tenderness

Adjunctive Tests

Imaging usually not indicated for uncomplicated patients CT scan may be indicated if suppurative complications suspected patient fails to improve after treatment or as pre-operative study

Ideally should be obtained after several weeks of medical therapy Major bony anatomic abnormalities unusual in children Mucosal inflammation common incidental finding in children and strongly

related to viral URI Incidence of sinus mucosal inflammation drops off after age 7 to 8

Sinus aspirate is indicated in severe toxic illness acute illness not responsive to antibiotics within 72 hours immunocompromised patients suppurative complications and workup for fever of unknown origin

OropharyngealNasopharyngeal swabs do not correlate with sinus aspirate Endoscopically guided middle meatus swab correlates fairly well with sinus

aspirate

Microbiology

Similar to adults Streptococcus pneumoniae Moraxella catarralis nontypeable Hemophilus influenzae

ICU patientscystic fibrosis Pseudomonas aeruginosa Staphyloccus aureus Resistant organisms more common in patients already treated with multiple

rounds of antibiotics children in day care children who have received antibiotic therapy in the last 30 days

Chronic pathogens may include

Alpha-hemolytic streptococci S aureus Nontypeable H inflluenzae M catarrhalis Anaerobic bacteria Pseudomonads

Medical Treatment

Acute Sinusitis Young children with mild to moderate ARS amoxicillin

at normal or high dose

Amoxil-allergic patients treat with a cephalosporinmdashsevere allergy treat with macrolide

Nonresponders more severe initial disease those at high-risk for resistant strep treat with high dose amoxilclavulanate

Parenteral ceftriaxone for children not tolerating oral meds

Duration of therapy is usually 10-21 days or until symptoms resolve plus 10 days

Medical Treatment

Chronic Rhinosinusitis

4 to 6 week course of beta lactam stable antibiotic

Adjuvant therapy with nasal steroids commonly employed

Antihistamines especially if underlying allergic condition suspected

Mucolytics may thin secretions

Refractory Rhinosinusitis

Consider associated conditions

Allergy

Immune deficiency

Asthma

Gastroesophageal reflux disease

Cystic Fibrosis

Primary Ciliary Dyskinesia (Immotile Cilia Syndrome)

Allergic Fungal Sinusitis

Allergy

Major contributing factor in rhinosinusitis Similar pathogenesis as viral etiology with obstruction -- mucostasis

--hypoxia ndash colonization Itching mucous membranes clear rhinorrhea eczema food

intolerance nasal congestion stuffiness fluctuating rhinorrhea sneezing cough behavioral changes headaches facial pressure

Avoidance clean allergy proof house filter no pets air conditioning

Pharmacotherapy antihistamines nasal steroids mast cell stabilizers

Immunotherapy

Immune Deficiency

History of frequent otitis media pneumonia and sinusitis may suggest a primary or secondary immunodeficiency state

Serum immunoglobulins and IgG subclasses should be checked as well as ability to respond to capsular antigens of S pneumoniae and H influenzae

Must have laboratory with age-appropriate norms

Chronic pediatric sinusitis associated with IgG2 deficiency

Consistent low total immunoglobulin defines common variable hypoglobulinemia

Treatment in primarily medical

Patients may benefit from IVIG therapy

Genetic counseling for patient and family may be appropriate

Asthma

Sinusitis and asthma frequently associated same underlying disease process or causal relationship

Sinonasalbronchial reflex

Aspiration

Treatment of sinusitis whether medical or surgical reduces use of bronchodilators improves pulmonary symptoms

Gastroesophageal Reflux Disease

Many pediatric patients experience improvement in their chronic sinonasal symptoms after a trial of antireflux medicine

GERD theorized to have direct effect on nasal mucosa initiating inflammatory response with edema and impaired mucociliary clearance

Phipps in 2000 reported a prospective trial in which 63 CRS patients were found to have esophageal reflux by pH probe 32 demonstrated nasopharyngeal reflux

Bothwell in 1999 reported 89 of pediatric candidates for FESS avoided surgery with treatment for GERD

Cystic Fibrosis

Autosomal recessive disease Mutation of CFTR protein Patients develop chronic pulmonary disease in childhood

also affected with sinusitis and nasal polyposis pancreatic insufficiency and biliary cirrhosis

If surgery contemplated check coags Recent studies suggest heterozygous mutations in the

CFTR gene are associated with chronic rhinosinusitis Raman found that 121 of CRS patients harbored CFTR

mutations compared with the expected rate of 3-4 Wang found a 7 incidence of CFTR mutation in 123 CRS

patients compared to 2 in a control group

Primary Ciliary Dyskinesia

History of chronic otitis media chronic sinusitis and chronic bronchitis or bronchiectasis

Kartagenerrsquos syndrome sinusitis situs inversus bronchiectasis and male infertility)

Diagnosis established with inferior or middle turbinate or tracheal biopsy

Allergic Fungal Sinusitis

Allergic reaction to aerosolized fungi usually of the dematiceous species

Treatment is surgical with perioperative oral steroid and post-operative topical steroids

High recurrence rate requires close follow up

Findings in children different than adult findings Children more frequently have

abnormalities of their facial skeleton

More likely to have unilateral disease

Complications

Orbital Orbital complications more common in

children than adults

Most common is medial subperiosteal abscess

Intracranial More common in adolescentsadults

Include meningitis (most common) epidural abscess subdural abscess intracerebral abscess cavernous sinus thrombosis

Orbital Complications

Classified by Chandler

I Preseptal cellulitis

II Orbital cellulitis

III Periorbital abscess

IV Orbital abscess

V Cavernous sinus thrombosis

Spread by direct extension via osseous structures or indirectly via valveless venous plexuses

Obtain CT scan with contrast if orbital involvement suspected

Stage ImdashPreseptal Cellulitis

Eyelid edema erythema and normal globe movement

Stage I in children more likely due to cutaneous lesions or hematogenous seeding rather than sinusitis

Stage IImdashOrbital Cellulitis

Proptosis Chemosis Edema Pain

Dilated pupil

Visual loss

Ophthalmoplegia

Afferent pupillary defect

Stage IIImdashPeriorbital Abscess

Proptosis with globe displacement inferolaterally decreased EOM vision decreased

IVAbx with external or endoscopic drainage of abscess and involved sinus

Stage IVmdashOrbital Abscess

orbital abscess

severe proptosis and chemosis

usually no globe displacement

opthalmoplegia present

Impaired visual acuity

Stage VmdashCavernous Sinus Thrombosis

Progressive symptoms

Proptosis and fixation

CN II IV VI

Meningitis

High mortality

High fever bilateral symptoms

Intracranial Complications

Meningitis Epidural Abscess Intracerebral Abscess Pottrsquos Puffy Tumor

Neurosurgical Consultation high-dose antimicrobial therapy drainage of intracranial abscess planned in concert with drainage of affected sinus

Frontal sinus is most implicated sinus venous drainage of the frontal sinus via small diploic veins extending through sinus wall these communicate with venous plexi of dura periorbita and cranial periostuem

Surgical Management

Adenoidectomy FESS

Only after maximal medical therapy has failed and patient has been screened and treated for any underlying conditions

Concern for developing nasal and sinus anatomy in children and possibility of altering facial growth

Pediatric Rhinosinusitis

Sarah Rodriguez MD

Faculty Advisor Matthew Ryan MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

May 2004